August 1, 2025
By Kevin Chan, OD, MS, FAAO, IACMM
When a prescribed treatment for myopia management works as planned, it helps patients and practitioners recognize and appreciate that cessation upon successful interventions is on the horizon. Intriguingly, however, there still isn’t much known on the subject of phasing out interventions for myopia management. In fact, it is a crucial, yet often underrated, step in developing a balanced, evidence-based approach for clinical efficacy, as well as a psychological progress, as patients are soon to transition out of active myopia treatment.
The Science Behind Treatment Cessation
Rather than cutting treatment off “cold turkey,” phasing out myopia management therapy involves gradually reducing the intensity or frequency of treatment sequentially. While the idea of tapering is seemingly confined to the use of low-dose atropine medication alone, it encompasses a comprehensive assessment for all myopia interventions. For optimal outcomes, this process warrants a thoughtful blend of approaches that involves both evidence-based research and individualized patient care.
The rationales are rooted in both biological and behavioral science:
- Sudden cessation of myopia therapies, especially for pharmacological agents like atropine, can potentially result in rebound effects, where myopia progression temporarily accelerates. As atropine is a muscarinic/cholinergic antagonist, depriving the anti-cholinergic receptors abruptly without preceding warning or preparation can result in opposite and undesirable effects. In other words, cholinergic receptors are likely bound preferentially, leading to extracellular matrix (ECM) remodeling, scleral fibrous thinning, as well as hypoxia.1,2 Ultimately, axial length (AL) could spike or elongate erroneously.
- Patients undergoing OrthoK or soft multifocal contact lenses aren’t necessarily immune from similar side effects when they opt to phase out. While the notion of phasing out these optical interventions appears unfamiliar or foreign, discontinuing the habitual lens wear regimen without gradual step-down approach can potentially result in unforeseeable intricate interactions with the surroundings. The imposed retinal signals induced by these optical interventions can take time to recalibrate. Abrupt shifts or shutdown of these signals may interfere with retinal responses.
- It is important to note that not all patients respond to therapy or its withdrawal in the same manner. However, little is known regarding how age, ethnicity and duration of treatment could influence the success of phasing out treatment.
Key Principles of Treatment Cessation
To achieve optimal clinical success without repercussions, it is recommended that practitioners consider the following:
- Slow and Steady: Reducing optical or pharmaceutical therapy dose or frequency should take place over months rather than weeks. For example, low-dose atropine might be tapered from nightly to every other night, then to twice weekly and then once weekly, before discontinuation.
- Periodic follow-up visits, including manifest refraction and axial length measurements, are essential. This helps detect any early signs of myopic rebound or relapse.
- Diurnal and seasonal variations of AL can play a role in assessing the progress in episodes. These factors should be taken into account when it comes to setting a regimen for phasing out treatment. In general, AL growth displayed in winter is inherently more rapid than summertime. In other words, patients tend to show better myopia control effects in the summer.3,4 Thus, practitioners should be cognizant of how a regimen to phase out treatment is administered accordingly.
- Age and duration of treatment matter. The process is generally more successful in older adolescents and young adults, where the natural progression of myopia has slowed or ceased. Nevertheless, these patients have also generally undergone a longer period of treatment throughout their development. For that, it is also crucial to plan ahead and engage in a conversation with them in the months, or even years, prior to transitioning out of the assigned treatment.
- For children using combined interventions, the phase-out process should start with one therapy while another is maintained. This creates a safety net against rapid progression.
The Art of Treatment Cessation: Keep Things Patient-Centered
While scientific principles guide the broad outlines of the phase-out regimen, the art lies in how the strategies are discussed and tailored to each patient.
Goal Setting for Mutual Understanding
Effective communication is paramount—even before treatment is initiated. Patients and families should understand the rationale for tapering, the signs of possible rebound and the importance of continued monitoring. Setting realistic expectations fosters cooperation and adherence.
In addition, high academic demands, where patients engage in more intense near work, can potentially impact AL growth episodically. Just because AL growth accelerates in a single visit does not always reflect true myopia progression. Rather, stable serial refraction data and cumulative axial length growth for a minimum of two years is strongly advised. Otherwise, further monitoring and treatment is warranted for a longer duration. Indeed, post-cessation follow-ups annually should be considered.
Upon treatment cessation, eye growth and myopia progression may return to faster, yet still age-expected emmetropic physiologic growth rates. For teenagers, this can range from 0.10 to 0.15mm annually, and for young adults, this is usually <0.1mm annually.5,6 Nevertheless, it can also be subject to patients’ preference, academic or vocational demands and the real treatment progress shown in adulthood.
While there is no universal, or one-size-fits-all protocol for phasing out treatments, making sound clinical judgment and engaging in thorough communication with patients is critical. Many young adults assume that they can be done with treatment for good as soon as they reach 16 years old (as if getting a driver’s license). However, age is not the sole determining factor. At times, I encourage having contingency plans for patients (e.g. postpone phasing out treatment until completion of SAT tests or major milestones) to ensure that they feel supported and heard.
Treatment Cessation: More than ‘Turning the Switch Off’
Discontinuing therapy in myopia management is multifaceted—it certainly involves sound clinical metrics and strategies. It also requires the clinician’s experience and the patient’s understanding and cooperation. The process must be flexible, patient-centered and rooted in shared decision-making. As research evolves, the realm of myopia management should no longer simply be about how to get started, but also how to close out treatment seamlessly.
For all practitioners, remember that the goal of phasing out myopia treatment is not merely to stop the intervention, like turning off a switch, but to carefully navigate through the murky trenches or unknown terrains confidently and strategically.
References
- Gallego P, Martínez-García C, Pérez-Merino P, Ibares-Frías L, Mayo-Iscar A, Merayo-Lloves J. Scleral changes induced by atropine in chicks as an experimental model of myopia. Ophthalmic Physiol Opt. 2012 Nov;32(6):478-84. doi: 10.1111/j.1475-1313.2012.00940.x. Epub 2012 Sep 17. PMID: 22978746.
- Huang L, Zhang J, Luo Y. The role of atropine in myopia control: insights into choroidal and scleral mechanisms. Front Pharmacol. 2025 Mar 20;16:1509196. doi: 10.3389/fphar.2025.1509196. PMID: 40183102; PMCID: PMC11965631.
- Ulaganathan S, Read SA, Collins MJ, Vincent SJ. Daily axial length and choroidal thickness variations in young adults: Associations with light exposure and longitudinal axial length and choroid changes. Exp Eye Res. 2019 Dec;189:107850. doi: 10.1016/j.exer.2019.107850. Epub 2019 Oct 19. PMID: 31639338.
- Tang T, Li Y, Zhao M, Wang K. Seasonal Variation in the Effect of Controlling Myopia Progression Using Orthokeratology. Eye Contact Lens. 2025 Jun 27. doi: 10.1097/ICL.0000000000001205. Epub ahead of print. PMID: 40572041.
- Bullimore MA, Brennan NA. Efficacy in myopia control-The impact of rebound. Ophthalmic Physiol Opt. 2025 Jan;45(1):100-110. doi: 10.1111/opo.13403. Epub 2024 Oct 8. PMID: 39377894.
- Berntsen DA, Ticak A, Orr DJ, Giannoni AG, Sinnott LT, Mutti DO, Jones-Jordan LA, Walline JJ; Bifocal Lenses in Nearsighted Kids (BLINK) Study Group. Axial Growth and Myopia Progression After Discontinuing Soft Multifocal Contact Lens Wear. JAMA Ophthalmol. 2025 Feb 1;143(2):155-162. doi: 10.1001/jamaophthalmol.2024.5885. PMID: 39821272; PMCID: PMC11843368.
